Chapter 28: Lesser

Metatarsal
Surgery
Anatomy (Metatarsals 2-3-4)
Differential Diagnosis of Metatarsalgia
Surgical Treatment of the IPK
Lesser Metatarsal Joint Replacement
Panmetatarsal Head Resection
Metatarsus Adductus
Freiberg's Disease
Tailor's Bunion
Splayfoot
Brachymetatarsia (Brachymetopody)
Skewfoot
 LESSER METATARSAL SURGERY
The central 3 metatarsals are usually grouped together because they do not
have individual axes of motion.

Anatomy (Metatarsals 2-3-4)

1. The deep transverse metatarsal ligament attaches to the plantar pad and
head of the central metatarsals on both sides. This affords greater stability to
the metatarsals 2-4 rather than to metatarsals 1 & 5

2. The plantar plate attaches to the metatarsal heads and the extensor hood
runs from dorsal to plantar to join at the inferior junction of the hood,
capsule, and deep transmetatarsal ligament

3. Blood supply to a long bone is via 3 sources:

a. Nutrient
b. Metaphyseal: In the metaphyseal region, there is an additional advantage
of having metaphyseal vessels adding a vascular system to bone
c. Periosteal: overlap entirely with the nutrient artery and so in most places
there is at least two supplies
4. Surgical neck is distal to the anatomical neck, and the condyles are
directly plantar to the flare between the two

5. There is a normal declination of the metatarsal of approximately 15°

Differential Diagnosis of Metatasalgia,

1. Local factors:
a. Stress fractures
b. Neuroma or neuritis
c. Intermetatarsal bursitis
d. Freiberg's infraction
e. Biomechanical factors:
i. Abnormality of metatarsal parabola resulting in plantarflexion,
shortening or elevation of a metatarsal
ii. Pes planus or pes cavus
g. Tumors
h. Arthritis (local as well as systemic)
i. Sesamoiditis
j. Tendonitis

2. Referred or systemic etiology:

a. Compression neuropathy of spinal cord L5-S3
b. Compression neuropathy of tarsal tunnel
c. Peripheral neuropathy
d. Ischemia

Surgical Treatment of the IPK

One should try to biomechanically evaluate why a lesion is present so that
the chances for return are reduced after correction of both the actual lesion
and the underlying cause.
1. Etiology of plantar lesions (metatarsals 2-4):
a. Biomechanical forces: Equinus, rearfoot varus, FF varus/valgus, adductory
twist
b. Hammertoe syndrome: Causes a retrograde plantarflexory force on the
metatarsal head. As the MPJ dorsiflexes due to muscular imbalances around
that articulation, the dorsal sling mechanism causes the proximal phalanx to
dorsiflex and apply a downward vector to the metatarsal. As time progresses,
there is a soft tissue contracture of the area and the metatarsal is exposed to
abnormal stresses
c. Atrophy or displacement of the plantar fat pad
d. Long or short metatarsal (even at the same declination angle)
e. Sagittal misalignment (abnormal declination angle): Abnormal
plantarflexed position, abnormal adjacent metatarsal, hypermobility
f. Abnormal bone shape (prominent plantar condyle)

2. Etiology of plantar lesions (metatarsal 5):

a. Biomechanical: Rearfoot varus, rigid forefoot valgus, forefoot varus
b. Sagittal malalignment: Abnormal plantarflexed 5th metatarsal,
plantarflexed cuboid, dorsiflexed 4th metatarsal
c. Congenitally long 5th metatarsal or short 4th metatarsal
d. Abnormal bone shape or size (prominent plantar lateral condyle)
e. Fat pad atrophy

3. Differential diagnosis:
a. Verruca plantaris: pinpoint bleeding, usually not directly on weightbearing
area, fast development, skin lines surround the lesion
b. Inclusion cyst: history of trauma (foreign body, puncture)
c. Scar tissue (history of trauma)
d. Foreign body

4. Preoperative considerations:
a. Mark the lesion with a x-ray opaque marker
b. Take x-ray in the angle and base of gait in full weight-bearing
c. Evaluate the metatarsal parabola (141.5°)
d. Check the axial view to evaluate the condyles
e. Look at the morphology of the metatarsal head and the relative position of
the fat pad

5. Summary of procedures: Can be done at the head, shaft, or the.

base of the metatarsal.
It is a good idea to enucleate the lesion prior to, or at the time of surgery to
hasten recovery of the plantar skin.
a. Procedures at the neck or head:
i. Percutaneous metaphyseal osteotomy (PMO):
 Osteotomy at the metaphyseal region where the capital fragment is
dorsiflexed
 Done so that the capital fragment is forced to the appropriate level when
walking
 The deep transverse ligament helps hold the the head in the correct
position, not allowing it to dislocate dorsally
 The cut is dorsal-distal to plantar-proximal to avoid the condyles and lift
the entire distal segment (fixation at the proper level)
ii. Transverse osteotomy:
 Similar to the PMO but done visually
 May be modified to shorten a metatarsal or fixated to control position
iii. "V" osteotomy:
 Done at the anatomical neck
 Gives good transverse and frontal plane stability due to the "V" cut
 Cut must include the condyles
 Apex is distal so the head and the phalanx act as one unit, so the head is
not free to dislocate
 Ambulation is allowed to force the head into the appropriate position
 Must debride or excochleate the lesion preop to avoid forcing the head too
high
 May impact on the shaft to control position
iv. Dorsiflexory wedge osteotomy (DFWO): A tilt up osteotomy
•Done at the anatomical neck or at the base (1 cm from the metatarsal-
cuneiform joint)
 Apex is plantar and the base-is dorsal
 Shortens the metatarsal
 Must be proximal to the condyles at the neck
 Must fixate
 Ambulation in a Reese® shoe
v. Arcuate osteotomy:
 Bone at the neck or base
 Special blade is needed (1800 arc)
 Allows for transverse and sagittal motion
 Must be fixated
vi. McKeever peg-in-hole:
 Shortens the metatarsal significantly
 Technically difficult
vii. Cylindrical stepdown osteotomy:
 For long metatarsal
 A cylindrical segment of bone is removed to cause shortening of the
metatarsal that needs fixation and NWB
viii. Chevron:
 A double "V" osteotomy with section removed used to shorten the
metatarsal
 Fixation must be used
 Cannot take too much bone due to the soft tissue attempting to maintain
length
 Cuts must be parallel and congruent
ix. Osteoclasis:
 Surgical fracture at the anatomical neck by forceps
 Semi-free floating head
 No heat from the power equipment, therefore, little bone necrosis
x. Metatarsal head resection and condylectomy:
 Helpful for subluxed and/or deformed joint
 Joint is basically removed
xi. Metatarsal head resection:
 For deformed or destroyed MPJ
 Shortens the ray
 Allows contracture of the toe but the pain from the lesion disappears
 Best done in the elderly
 Close and purse string the capsule
xii. Plantar condylectomy:
 Open the MPJ and elevate the metatarsal head to allow access to the
plantar condyles
 Condyles are resected and area rasped smooth
 Osteoarthritis can develop and joint limitus may develop as disruption of
the integrity of the MPJ is necessary
 No bone healing needed, therefore, early ambulation
b. Procedures at the shaft:
i. Giannestras step down osteotomy:
 For a long metatarsal
 Z" shortening of the metatarsal that needs fixation

c. Procedures at the base:

i. Cresentic: As described above
ii. DFWO: As described above

6. Complications of metatarsal osteotomies:

a. Transfer lesions develop (so try not to overcorrect by indiscriminate
elevation)
b. Dorsal bump develops from too much elevation without having
remodeled the head
c. Floating toe develops from destroying the internal cubic content of the
joint
d. Non-union occurs if ischemia is produced or no fixation or stabilization
of the osteotomy site exists
e. Flail toe from transection of the musculotendonous tissues surrounding
structures
f. Dislocation of the metatarsal head and deformed position of the head
or toe
g. Edema
h. Return of the original deformity due to not enough elevation of the
metatarsal segment

Lesser Metatarsal Joint Replacement

1. Indications:
a. Inflammatory arthritides: RA
b. Degenerative arthrosis secondary to:
i. Osteochondral fractures
ii. Osteochondritis dissecans
iii. Orthopedic deformity
iv. Joint subluxation
v. Malaligned fractures of the foot
vi. Trauma
vii. Previous surgery
viii. Congenital deformity
c. Congenital deformity- Brachymetatarsia
d. Flail toes
e. Floating toes
f. Revisional surgery

2. Types:
a. Swanson flexible hinge toe implant
b. Sgarlato double-stem cup implant (hinge avoided)
c. Swanson condylar implant
3. Surgical technique:
a. Lazy "S" Incision over the MPJ (less skin contracture)
b. Linear or "U" shaped capsulotomy
c. Preoperative soft tissue contractures eliminated via extensor/flexor
tenotomies and/or plantar plate/hood release
d. Bony resection (mostly metatarsal head)
e. Reaming the medullary canals (caution in the proximal phalanx)
f. Sgarlato recommends centralizing the flexor tendons via a drill hole in the
plantar portion of the phalangeal base and attaching the tendon by suture
g. Check fit with a sizer
h. Flush copiously
i. Wound closed in layers

4. Complications:
a. Implant instability: Pistoning can occur from removal of too much bone as
well as axial rotation of the implant
b. Implant failure: Mechanical stress can produce microfragmentation with
migration of the silicone particles into the lymphatic system. With this there
will be obvious loss of function and possible deformity
c. Foreign body reaction
d. Osteochondritis dissecans: From excessive stripping of the periosteum and
resultant avasular necrosis
e. Detritic synovitis reaction: The surgical area will become red and swollen
with a chronic low grade pain. Once infection is ruled out the patient can be
treated with NSAIDS or remove the implant device
f. Infection: Implant must be removed and not replaced for at least 6 months
to one year. If gram negative infection was present, implant should not be
replaced for longer period of time if at all
g. Pistoning of the implant into cancellous bone (if implant chosen is too
small)
h. Chronic edema
i. Fracture of the base of the proximal phalanx

5. Contraindications:
a. Severe osteoporosis of the involved bones (seen with RA)
b. History of a prior joint infection within the last 6 months
c. History of allergic reaction to implant material
d. Medically compromised patient (diabetic neuropathy, Charcot joint)

Panmetatarsal Head Resection

This procedure can be gratifying but must be performed only when the
proper criteria are met.
1. Historical:
a. Hoffman (1911): Transverse plantar approach
b. McKeever (1952): Dorsal longitudinal approach
c. Clayton (1963): Transverse dorsal approach for metatarsal head and
phalangeal base resections
2. Preoperative signs:
a. IPK's under most metatarsal heads
b. Atrophy of plantar fat pad
c. Ability to palpate prominent metatarsal heads
d. Dorsally contracted toes at the MPJ's
e. Possible contracted toes and proximal interphalangeal joint or distal
interphalangeal joint with associated lesions
f. Range of motion at the MPJ may be limited or painful or may be absent
g. Range of motion of the MPJ may elicit crepitus
h. Signs of degenerative disease and deformity
i. Patient ambulates with an apropulsive type gait
j. Ulceration of sub-metatarsal head area

3. Preoperative symptoms:
a. Moderate to severe pain on the plantar aspect of the forefoot when the
patient ambulates with or without shoes
b. Painful multiple hyperkeratotic lesions
c. Painful plantar ulcerations under the metatarsal heads area
d. Patient may complain of painful dorsally contracted toes when wearing
shoes
e. Patient complains of pain when most of the MPJ's are moved
f. Patient may complain that the toes cannot be straightened
g. History of metabolic disease (RA, psoriatic arthritis, etc.)

4. Preoperative x-ray evaluation:

a. Evidence of DJD
b. Dorsally contracted MPJ
c. Most of the MPJ's show evidence of DJD
d. Bone loss evident secondary to severe DJD
e. Proliferation of bone at the MPJ's
f. Loss of normal joint space
g. Cystic and erosive changes in the metatarsal heads
h. Generalized osteoporosis
i. Moderate to severe angulation deformity of the toes and metatarsals may
be present

5. Surgical procedure of choice:

a. 5 dorsal linear incisions: 3 dorsal linear incisions; or transverse incision
b. Maintain normal metatarsal parabola: The second is the longest, followed
by the 1st and third, followed by the 4th, and finally the 5th
c. The 1st metatarsal head is resected more medially than laterally
d. The lesser extensor tendons are usually tenotomized
e. Angulate the dorso-plantar cuts on all the metatarsal heads in order to
remove more bone plantarly than dorsally
g. Release the tourniquet prior to closing to prevent hematoma formation
h. K-wires can be used (helps eliminate the need for syndactylism)
i. Betadine soaked gauze can prevent postoperative edema and infection and
helps keep the toes in an aligned position

6. Advantages:
a. Eliminates painful MPJ's
b. Ability to ambulate without pain
c. Allows patient to wear regular shoes
d. Allows reduction of dorsally contracted toes in most cases
e. Elimination of plantar pressure points

7. Disadvantages:
a. Loss of propulsive gait
b. Flail toes postoperatively
c. Incidence of hematoma formation with resulting fibrosis
d. Destroys the function of the MTPJ's
e. Loss of digital stability

NOTE* if one excises a large amount of the metatarsal and one is already
dealing with short toes (especially the 5th), then syndactylism will aid in
achieving some stability of the area distally in the forefoot. This
procedure can be an adjunct to panmetatarsal head resection

Metatarsus Adductus
1. Clinical evaluation:
a. Adducted forefoot in the transverse plane with the apex of the deformity at
LisFranc's joint
b. Medial border concave with a deep vertical skin crease
c. Hallux widely separated from the 2nd toe d. The lesser digits will be
adducted at their bases
e. Occasionally the abductor hallucis may be palpably taut

2. Radiographic evaluation:
a. Increase in metatarsus adductus angle (greater than 200)

NOTE* Not always accurate as the lesser tarsal bones in the neonate are not
measurable as they are radiographically "silent", and in many cases the T-C
relationship is abnormal. Therefore It is best to use the calcanealsecond
metatarsal angle (normal parameters pending)

3. Indications for surgery

a. Failure to respond to conservative treatment
b. Residual deformity after treatment of talipes equinovarus
c. Newly diagnosed metatarsus adductus deformity

4. Considerations: (see section Pediatrics)

a. Age of patient
b. Osseous development
c. Severity of deformity
d. Presence of concomitant deformities
e. Extent of malfunction and disability

5. Soft Tissue Surgery: (current procedures will be discussed in

detail)
a. Heyman, Herndon, and Strong:
i. Indications:
 for flexible met. adductus which is reducible on manipulation (stress x-ray)
 usually children less than 5 years old
 deformity present at Lisfranc's joint, without significant bowing present in
the proximal portion of the metatarsal bones themselves
ii. Procedure:
 2 or 3 longitudinal dorsal incisions or transverse incision
 release of the dorsal, interossei, and plantar ligaments of the
tarsometatarsal joints and intermetatarsal joints
 preserve the plantar-lateral ligaments, especially 5th metatarsocuboid
articulation and the peroneus brevis tendon
 manipulate the foot into abduction
 K-wire fixation of the first met-cuneiform joint and 5th met-cuboid joint
 release of the naviculocuneiform and intercuneiform joints is rarely
needed
 consider abductor hallucis release or tenotomy in conjunction with HH&S
iii. Precautions:
 avoid damage to the 1st metatarsal epiphyseal growth plate (do not
confuse this with the met-cuneiform joint)
 be careful not to introduce iatrogenic dorsal dislocations at the met-
cuneiform joints
iv. Postop care:
 cast for 6-12 weeks
 manipulate the foot and recast every 3-4 weeks depending upon the
severity
 monitor the foot carefully for the development of a flatfoot deformity
v. Complications:
 dorsal dislocation
 degenerative arthritis
 damage to the growth plates

b. Thompson procedure (modified):

i. Indications:
 congenital hallux varus primarily
 flexible met. adductus secondarily
 hyperactivity of the abductor hallucis ms.
ii. Procedure:
 medial longitudinal 1st MTPJ skin incision approach
 dissection to level of deep fascia over the abductor hallucis muscle
 transection of the abductor hallucis tendon with resection of a segment of
the tendon and portion of the distal muscle
 consider lesser MTPJ release medially if lesser digits are also adducted
 release of the medial head of the flexor hallucis brevis if adduction of the
hallux is still present
iii. Precautions:
 do not reduce varus of the hallux without ensuring correction of any
adduction deformity of the first metatarsal
 place the medial incision over" the 1st MTPJ strategically; if too superior or
inferior, may damage the medial neurovascular bundle
 avoid the procedure as a primary mode of correction for met. adductus
unless clinical findings and x-rays strongly support hyperactivity of the
abductor hallucis as the primary etiology
iv. Postoperative care:
 weightbearing in a surgical shoe for 3-6 weeks
 splinting of the hallux and the first ray
v. Complications:
 hallux abductovalgus
 hallux hammertoe (hallux malleus)

c. Johnson osteochondrotomy: cartilaginous procedure

i. Indications:
 met. adductus deformity in children between the ages of 5-8 years (can be
younger)
ii. Procedure:
 3 dorsolongitudinal incisions
  closing abductory base wedge osteotomy of the 1st metatarsal
 wedge resection of cartilage and bone from the bases of the lesser
metatarsals, distal to the proximal articular surface (base is lateral with
the apex medial)
 fixation of the osteotomies with stainless steel wire, K-wires, or staples
iii. Precautions:
 avoid damage to the epiphyseal growth plate of the 1st metatarsal
 overcorrection/undercorrection of individual ray segments
iv. Postoperative care:
 non-weightbearing with cast immobilization for 6-8 weeks
 serial x-rays to assess healing

6. Osseous Surgery:
a. Modified Berman-Gartland procedure:
i. Indications:
 met. adductus in the child older than 6-8 years
 residual deformity following treatment of talipes equinovarus
ii. Procedure:
 3 dorsolongitudinal incisions
 transverse or oblique-type closing abductory wedge osteotomy of the 1st
metatarsal
 similar type of osteotomies of the lesser metatarsals with the cortical
hinge medially
 fixation of osteotomies with SS wire, K -wires, staples, AO screws or
combinations
iii. Precautions:
 avoid damage to growth plates of 1st metatarsal
 meticulous subperiosteal dissection is critical to avoid heavy callus
formation and undesirable synostosis between adjacent metatarsals
 preservation of the medial cortical hinge is important to insure stability
 careful planning to avoid over/undercorrection
iv. Postoperative care:
 non-weightbearing cast immobilization 6-8 weeks
 convert the cast to posterior splint and start PT
 orthotics when patient resumes weightbearing
 serial x-rays to assess bone position and healing at 3 weeks , 6 weeks, 12
weeks, 24 weeks and 1 year
v. Complications:
 over/undercorrection
 delayed union/nonunion/pseudoarthrosis
 fracture of f cortical hinge
 damage to growth plate
 elevatus of metatarsals
 iatrogenically induced flatfoot deformity

b. Lepird procedure:
i. Indications:
 met. adductus in the child older than 6-8 years
 residual talipes equinovarus deformity
ii. Procedure:
 3 dorsolongitudinal incisions
 oblique closing-abductory wedge osteotomy (Juvara type) of the 1st
metatarsal with AO/ASIF screw fixation
 rotational osteotomy of each lesser metatarsal with AO/ASIF screw fixation
(2.7 mm cortical used mostly) perpendicular to the plane of the osteotomy
 an oblique closing wedge osteotomy may be used on the 5th metatarsal in
place of the rotational type (if preferred)
 rotational osteotomies are performed from dorsal-distal to plantar
proximal with temporary preservation of the cortical hinge (facilitates
fixation). The osteotomy is approximately 45° from the weightbearing
surface. The precise angle will depend on the declination of the metatarsal
segment. As the declination of the metatarsal increases, the osteotomy
will be more parallel to the weightbearing surface of the foot
 area of the cortical hinge preserved is most commonly proximal/plantar
 the screws are then removed and the osteotomy is completed
 the screws are reinserted, the distal fragments are rotated laterally, and
the screws are tightened
 the alignment of the foot is assessed; if realignment is necessary the
 screw(s) can be loosened and the bone adjusted
iii. Postoperative care:
 same as Berman-Gartland
iv. Complications:
 same as Berman-Gartland
 if the osteotomy is performed too vertically the rotation of the
 osteotomy will be around the longitudinal axis of the metatarsal bone
itself, resulting in inversion/eversion of the bone itself v. Advantages: this
procedure is amenable to rigid internal fixation and primary bone healing
 over/undercorrection can be corrected during surgery
 biplanar correction can be achieved
 eliminates pin tract infections

7. Ancillary Procedures:
a. Equinus Deformity:
i. TAL
ii. Gastrocnemius recession
b. Flatfoot Deformity:
i. STJ arthroereisis
ii. Evans calcaneal osteotomy
iii. Modified Young's tenosuspension/ Modified Kidner procedure
arthrodesis/ N-C arthrodesis

Freiberg's Disease
Also known as osteochondrosis of the metatarsal head or avascular (aseptic)
necrosis of the bone, most commonly affects the 2nd metatarsal
1. Etiology:
a. Trauma (or trauma followed by fracture)
b. Ischemia
c. Prominent plantar metatarsal head with excessive loading with a
compromise to the circulation to the subchondral bone
d. Often appears after age 13, affecting women 3 times more frequently than
men

2. Signs and symptoms:

a. Pain in the MPJ (usually dorsally), either sharp, dull, or aching In character
b. Edema with increased activity
c. Limitation of motion of the involved digit and MPJ
d. Palpable irregularities may be present dorsally
e. Distal distraction of the toe will cause pain
f. Adjacent MPJ hyperkeratoses may be present as the Involved metatarsal
bears less weight

3. X-ray evaluation:
a. The initial findings include a joint space widening 3-6 weeks after the onset
of symptoms
b. This is followed by increased density of subchondral bone
c. As the disease progresses, a zone of rarefaction develops surrounded by a
sclerotic rim
d. With time, the epiphyseal bone weakens and collapses with the formation
of spicules and loose bodies
e. Flattening of metatarsal head with osteophytic lipping
f. Joint narrowing
g. Peripheral soft tissue swelling
h. Bone margins are sclerotic

4. Treatment:
a. Directed toward preventing further damage and displacement of the MPJ
(casting and cortisone shots followed by orthoses))
b. Later stages:
i. Implant arthroplasty: If symptoms are due to joint arthritis
ii. Metatarsal head remodeling (must preserve the alignment of the toeuse
splint 3 months postoperatively)
iii. Bone grafts (Smillie): To restore the contour of the metatarsal head by
inserting a cancellous graft (good for stage 1-3)
iv. Rotational osteotomies (Gauthier and Elbaz): Rotates the lower aspect of
the metatarsal head dorsally after a section of damaged cartilage has been
excised. This allows the plantar cartilage to articulate with the proximal
phalanx

NOTE* Dr. Freiberg's only surgical treatment involved removing the loose
bodies
5. Classification (by Smillie into 5 stages):

a. Stage 1: Fissure fracture

b. Stage 2: Absorption of bone. Central aspect of bone is sinking into the
metatarsal head
c. Stage 3: Further. progression with projections remaining on either side of
the metatarsal head. The plantar articular cartilage remains intact
d. Stage 4: Fractures and loose bodies may occur. Plantar cartilage no longer
intact
e. Stage 5: Flattening of the metatarsal head.

Tailor's Bunion
1. Etiology:
a. Any uncompensated varus position of the forefoot or rearfoot in a fully
pronated foot
b. A congenital plantarflexed 5th ray deformity
c. A congenital dorsiflexed 5th ray deformity
d. Idiopathic
e. Lateral deviation or wide 5th metatatarsal head
f. Combined influences

2. Clinical findings:
a. Prominence over the 5th metatarsal head with pain
b. Hyperkeratosis and erythema over the 5th metatarsal head area
c. 5th toe assumes a varus or adducto varus attitude

NOTE* Must determine if a splayfoot deformity is present. Evaluate on

weight-bearing and x-ray. Radiographically, splayfoot deformity is 3.
characterized by an IM angle between the 1st and 2nd metatarsal of
greater than 12° and between the 4th and 5th metatarsals of greater
than 8°. In association with varus of the 1st metatarsal, the slant of
the distal articular surface of the medial cuneiform is more than 105°
Radiological findings:-6 types according to the findings
a. Rotation of the lateral plantar tubercle into a lateral position
b. Increased IM angle (normal 6.47°): People with tailor's bunion have an IM
of 8.71 or greater (Fallat and Buckholz)
c. Increased lateral deviation angle (normal 2.64°) People with tailor's bunion
have a lateral deviation angle of 8.05° (Fallat and Buckholz)
d. A large "dumbell-shaped" 5th metatarsal head
e. Arthritic changes resulting in exostosis formation at the 5th MPJ
f. Any combination of the above conditions, the 1st three being most
common

4. Surgical management:
1. Hohmann osteotomy: Single transverse osteotomy at the level of the
metatarsal neck with medial displacement of the capitol fragment
b. Oblique osteotomy from distal lateral to proximal medial with
displacement of the capital fragment proximally and medially (reverse Wilson
procedure)
c. Modified Mitchell: Step down osteotomy
d. Austin type osteotomy: 2 mm of medial transposition
e. Mercado osteotomy: Medially based closing wedge osteotomy at the
metatarsal neck
f. Yancy osteotomy: Midshaft medially based closing wedge osteotomy
g. Gerbert et al osteotomy: Proximal diaphyseal closing wedge osteotomy
h. Buchbinder osteotomy: DRATO
i. McKeever: Partial metatarsal head resection
j. Kelikian: Partial metatarsal head resection with syndactylization of the 4th
and 5th toes
k. Distal oblique osteotomy with intramedullary K-wire fixation
 NOTE* Excessive 5th metatarsal head resection results in laxity of the
internal cubic content of the joint leading to further varus or adducto
varus malalignment of the 5th toe, and more retrograde pressure on
the 5th metatarsal head
Splayfoot
As this deformity consists of high IM angles for the 1 st and 2nd , and 4th and
5th, surgical repair is focused on reducing the IM angles. This is accomplished
via a closing base wedge osteotomy of the 1 st metatarsal with AO fixation,
and distal oblique osteotomy of the 5th metatarsal with K-wire fixation.

Brachymetatarsia (Brachymetapody)
1. Etiology:
a. Congenital: Premature idiopathic closure of the distal epiphyseal growth
plate
 NOTE* The congenital pattern has also been associated with neonatal
hyperthyroidism, pseudohypoparathyroidism, pseudo- b.
pseudohypoparathyroidism, malignancy, Down's syndrome,
Albright's syndrome, myositis ossificans, Turner's syndrome, sickle-
cell anemia, Still's disease, and enchondromatosis
Traumatic
c. Infectious

2. Clinical presentation:
a. Symptoms usually appear in adolescence when full growth discrepancy is
most apparent
b. In the younger patient the only complaint will be the appearance of a
shortened or "floating" toe
c. The adjacent toes underlap the involved toe
d. Calluses under the adjacent metatarsal heads with metatarsalgia
e. The amount of associated disability typically depends upon the amount of
weight that Is transferred to the adjacent metatarsal heads
f. A deep sulcus is present underneath the short metatarsal

NOTE* The iatrogenic and traumatically induced types of brachymetatarsia

are usually more acute and severe in their presentation

3. Radiological findings:
a. Short, underdeveloped metatarsal with deficient bone content
b. Osteoporosis of the metatarsal head

4. Operative planning:
a. Consider the amount of length needed to restore the normal metatarsal
parabola
b. Must consider whether to lengthen and plantarflex the involved metatarsal
or shorten and dorsiflex the adjacent metatarsals
c. Soft tissue mobility and neurovascular status of the involved ray
d. Use of a bone graft either autogenous or allogeneic

5. Procedure:
a. Bone lengthening procedure (frontal plane "Z" osteotomy)
b. Insertion of corticocancellous bone graft
c. Extensor tenotomy
d. " V" to "Y" skin plasty
e. BK NWB cast until osseous healing

6. Complications:
a. Risk of neurovascular compromise
b. Non-union
c. Absorption or collapse of the graft
d. Painful pseudoarthrosis
e. Painful limitation of motion at the joint

Skewfoot
1. Description: A metatarsus adductus forefoot-type with a pathological
rearfoot valgus component

2. Etiology:
a. After serial casting for metatarsus adductus in which the rearfoot was in a
pronated position
b. Untreated metatarsus adductus which has compensated by excessive
subtalar joint pronation
c. Congenital metatarsus adductus with associated calcaneovalgus

3. Clinical evaluation:
a. The metatarsals are angulated medially
b. The base of the 5th metatarsal is prominent
c. A large space is noted between the hallux and 2nd toe
d. A metatarsus varus may be present
e. The digits are abducted in stance
f. Talar bulging (ptosis) on weight-bearing with low medial arch
g. Abducted midfoot position with internal rotation of the malleoli
h. Rearfoot equinus may be present

4. Types:
a. Simple skewfoot: An adducted forefoot with an abnormally pronated
rearfoot
b. Complex skewfoot: An adducted forefoot, abducted midfoot, and
abnormally pronated rearfoot

5. Radiological evaluation:
a. Increased metatarsus adductus angle (MA angle greater than 21 °)
b. Increased cuboid abduction angle (greater than 5°)
6. Indications for surgery:
a. Too old for correction by conservative means
b. Deformity is increasing despite conservative treatment
c. Deformity is obviously not manageable by conservative means
d. Deformity is beginning to cause secondary deformities
e. Patient is experiencing painful compensatory symptoms
f. Patient is accommodating to life style because of related symptoms
g. Increased difficulty with standard shoegear

7. Surgical repair: As this Is a complex deformity, multiple

procedures must be employed as necessary
a. Equinus correction: Gastrocnemius recession or TAL as indicated
b. Pes valgoplanus correction: Evans opening calcaneal osteotomy and
medial arch tenosuspension. The Evans osteotomy lengthens the lateral
column and therefore, realigns the midtarsal joint

NOTE* This procedure can unmask a previously unappreciated metatarsus

c. adductus
Metatarsus
adductus correction: Modified Berman-Gartland or Lepird
d. Subtalar joint instability and bony adaptation: STJ arthrodesis